Presidential Speech at the 10th Annual Conference of Association of Cutaneous Surgeons (I), 25-27 November 2011, Kaziranga, Assam, India: Role of Association of Cutaneus Surgery - Past, Present and the Future

Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail.

Background : A full-thickness soft tissue defect closure often needs complex procedures. The use of dermal templates can be helpful in improving the outcome. Objective : The objective was to evaluate a sandwich technique combining the dermal collagen-elastin matrix with skin grafts in a one-stage procedure. Materials and Methods : Twenty-three patients with 27 wounds were enrolled in this prospective single-centre observational study. The mean age was 74.8 ± 17.2 years. Included were full-thickness defects with exposed bone, cartilage and/ or tendons. The dermal collagen-elastin matrix was applied onto the wound bed accomplished by skin transplants, i.e. 'sandwich' transplantation. In six wounds, the transplants were treated with intermittent negative pressure therapy. Results : The size of defects was ≤875 cm 2 . The use of the dermal template resulted in a complete and stable granulation in 100% of wounds. Seventeen defects showed a complete closure and 19 achieved a complete granulation with an incomplete closure. There was a marked pain relief. No adverse events were noted due to the dermal template usage. Conclusions : Sandwich transplantation with the collagen-elastin matrix is a useful tool when dealing with full-thickness soft tissue defects with exposed bone, cartilage or tendons.

Objective : The aim was to evaluate the effect of honey dressing and silver sulfadiazene (SSD) dressing on wound healing in burn patients. Materials and Methods : We retrospectively reviewed the records of 108 patients (14-68 years of age), with first and second degree burns of less than 50% of the total body surface area admitted to our institution, over a period of 5 years (2004-2008). Fifty-one patients were treated with honey dressings and 57 with SSD. Time elapsed since burn, site, percentage, degree and depth of burns, results of culture sensitivity at various time intervals, duration of healing, formation of post-treatment hypertrophic scar, and/or contracture were recorded and analyzed. Results : The average duration of healing was 18.16 and 32.68 days for the honey and SSD group, respectively. Wounds of all patients reporting within 1 h of burns became sterile with the honey dressing in less than 7 days while there was none with SSD. All wounds treated with honey became sterile within 21 days while for SSD-treated wounds, this figure was 36.5%. A complete outcome was seen in 81% of all patients in the "honey group" while in only 37% patients in the "SSD group." Conclusion : Honey dressings make the wounds sterile in less time, enhance healing, and have a better outcome in terms of hypertropic scars and postburn contractures, as compared to SSD dressings.

Background/Aim : Intralesional bleomycin gained increasing popularity in the recent past for treatment of warts particularly in palmo-plantar and periungual regions as other modalities are not very effective. Hence we evaluated the role of intralesional bleomycin in periungual and palmo-plantar warts to know its efficacy in Indian patients. Settings and Design : This was a placebo-controlled study. Materials and Methods : Fifty patients of multiple palmo-plantar and periungual warts were included in this study and categorized in groups A and B of 25 each. Alternate patients were included in groups A and B and treated respectively with intralesional bleomycin (1 mg/mL solution) and normal saline as placebo, fortnightly for maximum up to two injections. Patients were followed up weekly for 1 month, fortnightly up to 12 weeks, and then quarterly for 1 year. If warts persisted after 12 weeks of starting treatment, it was considered a failure. Statistical analysis was done by the chi-square test using M-stat software. Results : Group A and B patients were having 85 warts and 72 warts, respectively. The cure rate in group A and B patients was 96.47% (82/85 warts) and 11.11% (8/72 warts), respectively, after one or two injections within 12 weeks. The difference in the cure rate between two groups was statistically highly significant (<0.0001). In group A patients, a haemorrhagic eschar was formed which gradually healed in 8-12 weeks without atrophy or pigmentation; this phenomenon was not seen in group B. Only moderate pain was observed by most of the patients during injection in both groups. Conclusion : The intralesional injection of bleomycin is highly effective, safe, and non-toxic in periungual and palmo-plantar warts.

Background : Chronic pilonidal disease is a common debilitating condition. It is a cause of considerable morbidity and social embarrassment. This prospective randomized study compared permanent laser hair removal following the excision of pilonidal disease with conventional methods for hair removal. Materials and Methods : Patients undergoing surgery for pilonidal disease were randomized to two groups: those using laser hair removal methods following completed healing of wounds (group I) or regular post-healing conventional methods for hair removal, mainly razor and depilatory creams, for at least 6 months (group II). Group I patients received regular, monthly laser hair treatment sessions using Alexandrite laser for four sessions. Results : Group I patients had a mean age of 23.6 ± 4.7 years. Group I patients had monthly laser hair removal session and then they were regularly followed up within the proposed schedule. They found the procedure comfortable with no complications. Group II patients had a mean age of 23.7 ± 6.6 years; they reported difficulty in maintaining hair removal with these conventional methods, and mostly, by the end of the first year, all cases stopped maintaining regular hair removal. Recurrence occurred in Group II patients (two cases) mostly due to failure in maintaining hair removal and area hygiene. Conclusions : We advocate the use of laser epilation after surgery for pilonidal sinus as it decreases the chance of recurrence but larger studies with long-term follow-up are still needed to approve this conclusion.

Background : Cutaneous horns are hard, yellowish gray cornified skin growths. They are more common in white races and believed to be rare in Africans. There are few case reports of the lesion in African populations in the English literature. Materials and Methods : This report documents six patients with this lesion seen over a fourteen month period. There were three males and three females, aged 22 to 62 (mean= 47). Results : One lesion was on the scalp, the remaining on the extremities. The underlying pathologies were squamous cell carcinoma (1), Kaposi sarcoma (1), cutaneous myxoma (1), eccrine poroma (1) and the remaining two showed only chronic inflammatory changes with subepidermal lymphocytic and macrophage cell infiltrates. Conclusion : Unless cases are well documented, the perception of rarity in Africans will most likely persist. The risk of underling malignancy underscores the need for detailed evaluation and prompt management.

Radical surgery of fronto-temporal non-melanoma skin cancer (NMSC) sometimes causes palsy of the frontal facialis branch. Patients may experience visual impairment due to brow and upper eyelid ptosis. Since NMSC predominantly affects elderly people, the corrective surgical procedures have to be adapted to age, comorbidities and individual needs. The direct brow lift and the upper lid blepharoplasty are two reliable and safe surgical techniques with proved efficacy. Here we present our way to deal with post-surgical brow and lid ptosis.

Solitary angiokeratoma circumscriptum (AC) of the tongue is a rare entity. We present a case of solitary AC over the ventral surface of the tongue present for 3 years. The patient was treated with a combination of carbon dioxide (CO 2 ) and pulsed dye laser (PDL). There was more than 75% improvement in the lesion after treating with alternate sessions of CO 2 and PDL.

Gingival hyperpigmentation is caused by excessive deposition of melanin in the basal and suprabasal cell layers of the epithelium. Although melanin pigmentation of the gingiva is completely benign, cosmetic concerns are common, particularly in patients having a very high smile line (gummy smile). Various depigmentation techniques have been employed, such as scalpel surgery, gingivectomy, gingivectomy with free gingival autografting, cryosurgery, electrosurgery, chemical agents such as 90% phenol and 95% alcohol, abrasion with diamond burs, Nd:YAG laser, semiconductor diode laser, and CO 2 laser. The present case report describes simple and effective depigmentation technique using semiconductor diode laser surgery - for gingival depigmentation, which have produced good results with patient satisfaction.

Infantile haemangioma (IH) frequently requires no intervention. Eighty percent of IHs are focal and solitary. Fifteen percent of cutaneous haemangiomas occur on the extremities. A large size or a specific location or both may carry complications such as ulceration which is one of the main complications, and active treatment is usually required to manage pain, potential scarring, and occasionally, bleeding and infection. Oral propanolol is used in the treatment of IH and is found to be an effective treatment for complicated IH, replacing systemic corticosteroids as first-line therapy. Recommendations for instituting treatment with propranolol in infants differ among different specialties and academic centres. We report an infant with ulcerated IH of leg who responded dramatically to treatment with propranolol in 4 months.